Introduction: Networked Health Governance and the Dilemma of State Legitimacy in the DRC
In war-affected settings and ‘fragile’ states, the provision of social services is not solely the responsibility of the state, and the state is not the only actor striving for social control. Both state and non-state actors engage in the provision of social services. This shared responsibility for population welfare transforms the public sector into a space where public authority and social control are disputed between the state and non-state actors. This chapter presents the general conclusions regarding the engagement of non-state actors in the provision of public health services, networked health sector governance and the legitimacy of the state in the fragile setting of the Democratic Republic of Congo (DRC).
Public health governance in the DRC is the reflection of a public policy sphere characterised by interaction, cooperation and even competition between state and non-state actors. In this public policy sphere, the effectiveness of the state mostly depends on non-state service providers’ (NSPs) engagement and interventions, which take the form of networked health governance. However, this contributes to a state legitimacy dilemma, with empirically weak state institutions and multiple stakeholders disputing public authority. Hence, networked governance through interactions between the state and NSPs can be a double-edged sword for state-building legitimacy in conflict-affected and fragile states: On the one hand, networked governance through multi-stakeholder interactions does undoubtedly contribute to empirical statehood. However, on the other hand, this networked governance also turns the public service sphere into a field of competition and dispute over popular legitimacy. Legitimacy of the state, understood in the sense of how the citizens treat the state as rightfully holding and exercising political power (Gilley, 2006b), is a social variable with multiple factors.
This thesis attempted to unravel questions about the health sector networked governance and its contribution to the legitimacy of the state in the DRC. The study explored the state-building outcomes of networked health sector governance, especially concerning policy coalition-building and resource-based interdependency, the strengthening of system management, and the effectiveness of health service provision through state and non-state interactions. Embodied through these interactions between state and non-state actors, the health sector networked governance is operational in the structural governance of
policy-making processes at national level, health system management at intermediate level and health service provision processes at the operational/grassroots level.71
Non-state actors such as I/NGOs, faith-based Organisations (FBOs), community-based organisations (CBOs), UN agencies and a range of donor organisations fill the vacuum left by the weak state in the provision of basic public services. In the public health sector, NSPs act as either state partners or surrogate state-like service providers. NSPs may be categorised as traditional or situational partners. FBOs are classified as national but also traditional partners.
Most INGOs fall into the category of partners that were spurred by situational variables of state fragility, population vulnerability and the humanitarian consequences of the wars.
Traditional international partners—in collaboration with the Ministry of Health (MoH)—
contribute to the process of national policy making, sector funding and system strengthening.
This is regarded as a horizontal approach. Humanitarian actors mostly use a vertical approach, which aims to implement un-integrated projects and humanitarian interventions that focus on (extreme) vulnerability.
A great deal of previous scholarly work has focused on the link between legitimacy and state service delivery, but there has been little investigation of the link between basic service provision by NSPs and state legitimacy in fragile states. This study focused on the state-building outcomes of networked health sector management concerning effective public health governance, the strengthening of system management and health service provision through state–non-state interactions. The study also explored state legitimacy and the population’s experiences and perceptions of the state. Hence, the present work problematised service delivery and state legitimacy where the state is deemed fragile, has been affected by entrenched conflicts (or is contested) and relies heavily on NSP inputs. This led to the central research question of this study:
How does the networked governance of health services, involving state and non-state actors through multi-stakeholder interactions, affect state-building and legitimacy in the fragile setting of eastern Democratic Republic of Congo?
In view of better tackling the research problem, the above fundamental question was split into five sub-questions, which were addressed in the empirical chapters of this thesis:
71 Please See Chapter 4 for an explanation of structural governance.
1. How does the health system management characterised by multi-stakeholders’
engagement function, and how has this de facto networked governance been relevant for the state-building process in the fragile context of the DRC? (Chapter 2)
2. How do key stakeholders—especially state and donor organisations—intervening in the health sector use the discourse on state fragility in their interactions, and how does this impact intervention programming and policy coalition-building in the fragile state of the DRC? (Chapter 3)
3. What are the outcomes of strengthening the health system governance by means of networked governance through multi-stakeholder process initiatives such as the introduction and implementation of performance-based financing (PBF) in the health sector in the context of state-building in the fragile state of the DRC? (Chapter 4)
4. How do arrangements inspired by non-state actors, such as community-based health insurance (CBHI) schemes, affect networked governance and the achievement of universal primary health care coverage in war-torn communities experiencing excessive financial hardship and state fragility in South Kivu? (Chapter 5)
5. How do health services provided by non-state actors in the DRC affect popular perception of the state in the context of limited statehood? (Chapter 6)
Research Findings and Policy Implications Regarding Networked Health Sector Governance and State-building (Legitimacy) Outcomes in the Fragile State of the DRC The findings of this research revolved around three main themes through which the state-building outcomes of networked health sector governance were explored: i) the design of networked governance and international intervention models; ii) review of the two multi-stakeholder governance schemes fostering networked governance—PBF and CBHI/MUS; and iii) the exploration of population perceptions and the popular legitimacy of the state. These three research areas gave rise to five empirical chapters answering the five questions above.
The findings are summarised in this section.
Findings on the Functioning of Networked Governance, its State-building Outcomes and International Intervention Models
This sub-section answers the first two questions, which played a key role in understanding the overall workings, challenges and state-building outcomes of health sector networked governance through multi-stakeholder interactions. The first question concerns the workings and state-building outcomes of health sector networked governance in the fragile DRC health sector. The second question is mostly about the impact of state fragility discourse on health policy coalition-building, health sector intervention planning in light of the Paris Declaration on Aid Effectiveness, and the mutual perceptions of the state and international organisations.
Networked health sector governance through interactions of the state and NSPs may contribute to state-building in a fragile context.
A wide range of stakeholders interact to solve public and community health-related issues in the DRC. Four principal themes emerged from the analysis.
First, and above all, Chapter 2 revealed that the DRC health sector is an arena of networked governance. Although networked governance is not yet fully developed or completely institutionalised, throughout the health sector, there are many examples of state and non-state service providers negotiating, cooperating and even competing. In this sense, the Congolese health sector can be seen as an arena fostering the networked governance.
Second, interactions between state and non-state actors through this networked governance explain the persistence of the health sector in a setting characterised by very weak empirical statehood and a corrupt political elite. All of the chapters of the thesis have shown the concrete value of state–non-state interactions and partnerships for the maintenance and development of the health sector. The value of these interactions was acknowledged by a wide range of actors participating in this study. It is clear that non-state interventions fill the void where the state exists in name only, and non-state actors have undoubtedly contributed to meeting the population’s needs.
Third, during interactions with the state, power relations are skewed in donors’ favour because of their dominance in terms of resources, causing the state to play a limited role in managing the health sector. Pervasive institutional fragility compounded by deep-rooted corruption results in acute social vulnerability and disputed statehood. This, in turn, deeply
influences donors’ leverage, mostly in terms of intervention models and incomplete policy coalition-building. This was especially clear in Chapter 3, which dealt with the wide gap in the discursive understanding and the objectives of the state and its international ‘partners’
with regard to the state’s role in the governance of the sector. The research showed that, in a context of fragility, the state has limited power in negotiations with its partners on public matters. In addition to being hampered by weaknesses in terms of a lack of capacity for governance and (allegations of) misconduct, the Congolese state has also faced the challenge of interacting with partners with fragmented and horizontally competing agendas.
Consequently, building a policy community has been difficult, and the governance network continues to be strained in the DRC’s health sector.
Fourth, although it remains weak, the shadow of state authority is present in stakeholders’
interactions, and the state, as the legal sovereign, plays a determining role in providing a regulatory framework and hence in managing the formal room for manoeuvre available to non-state actors.
Ultimately, although health sector networked governance cannot fully address state weaknesses, the research revealed that networked governance facilitates the management of population health needs. However, strengthening the role of the state in networked governance emerged as a requisite for balancing power relations among key stakeholders to reinforce the state’s stewardship role, which is crucial for the coordination and the harmonisation of stakeholder interventions. This is necessary for achieving state-building process outcomes. Therefore, the issue of networked governance effectiveness raises normative concerns about the nature, model and priorities of engagement for policy interventions in empirically weak states, as well as about the role of the corrupt elite.
The perceptions and use of state fragility discourse in health sector programming, stakeholder interactions and stakeholder engagement negatively affect the process of health policy coalition-building in the DRC health sector.
Chapter 3 explored the impact of the state fragility discourse in interactive processes of state, INGO and donor engagement in the health sector in light of the Paris Declaration on Aid Effectiveness in fragile states. In the health sector, state fragility and its discursive referent hamper the formation of a policy coalition, because the government and donors/INGOs have not harmonised their perceptions of fragility. The present study used critical discourse
analysis to understand the extent to which the state fragility discourse influences key stakeholders’ intervention programming and policy coalition-building in the DRC health sector, yielding the following research findings:
State fragility impacts donors’ coordinative discourse on intervention programmes in the DRC health sector.
Diverging perceptions and discursive referents of state fragility also affect compliance with the Paris Declaration on donors’ alignment and recipient countries’ ownership.
In the domain of public health, state fragility appears to be a concept without a policy coalition, especially because the phrase means different things to different stakeholders.
This divergence in discursive references to state fragility did not, however, stop state officials from recognising the role of the financial inputs of INGOs/donors in the survival of the health sector.
The inputs of INGOs and donors into health services in the DRC health sector have followed both vertical and horizontal models. Most INGOs follow the vertical, humanitarian intervention model. However, state representatives emphatically expressed their aspiration to system/horizontal engagement for health system-building. Discursive references to state fragility were a sore issue among INGOs, donors and the state concerning health sector transition intervention models. Therefore, donors rationalised their emergency-based interventions, the shadow alignment (in place of a sector-wide approach) and indirect channelling of funding through INGOs by complaining about state fragility. State officials asserted political statehood and a desire for a paradigm shift. Dissent in perceptions of state fragility and the resultant model of engagement in the sector also affected the mutual perceptions of state and non-state actors. State fragility as a concept has therefore dominated interactive processes between the state and its partners.
State fragility is not a neutral concept in a context of contested statehood and disputed state legitimacy, where political elites attempt to assert statehood. In this study, discursive references to state fragility were viewed as empowering for INGOs and disempowering for the state. The research revealed how the use of state fragility as a perceptive discourse was interpreted differently by different actors in the DRC health sector. For government officials, the concept was seen as stigmatising, making it difficult for the state to assert its policy
perspective, especially regarding partners’ compliance with the Paris Declaration. For INGOs/donors and UN agencies, it was necessary to take contextual fragility constraints into account when interpreting the Paris Declaration.
The defective financing of the public health sector nevertheless constituted a common ground on state fragility discourse for the state and donors. Both groups of actors recognised the state’s weakness in terms of resource mobilisation, allocation, disbursement and control. The state’s slim budget and low disbursement rate have exposed the sector to dependency on external assistance. Many participants in this study noted that, without donors, the sector would be further weakened and would possibly collapse. However, the choice of intervention model, informed by the organisational stance on the state fragility discourse, was a point of contention in the process of policy coalition-building.
Considering the current situation, building a policy coalition based on harmonised views is necessary for effective engagement and intervention sustainability in the health sector. This coalition-building should promote more than the implementation of the Paris Declaration on alignment, also facilitating the accountability and social responsibility of all stakeholders, which is key in responding to empirical fragility.
Multi-stakeholder Health System Management Arrangements: Strengthening Networked Health Governance and Increasing Community Health Coverage
This sub-section is concerned with the questions on the workings and outcomes of two multi-stakeholder health governance arrangements in the DRC. The first question deals with the outcomes of PBF for strengthening health system governance in the context of state fragility in line with its state-building-oriented theory of change in the DRC. The research explored PBF outcomes on structural governance, health system management and demand-side empowerment for social accountability. The second question concerns CBHI (known in the DRC as Mutuelles de Santé, MUS), a multi-stakeholder health sector governance arrangement at local level, and the achievement of universal primary health care coverage in South Kivu.
The findings revealed how CBHI/Mutuelles de Santé has been a public sphere where different health sector stakeholders engage in the process of health system governance. The results also provide an understanding of the outcomes of MUS schemes regarding equity in primary health care coverage, social protection and health services financing at the community level in the diverse settings of the Katana and Uvira health zones (HZs).
PBF is a multi-stakeholder health sector governance arrangement that has contributed to strengthening health governance, improving health system management at intermediate level and ameliorating health provision processes at local level, especially in the Katana HZ.
In Chapter 4, PBF’s health governance-strengthening outcomes were explored in light of a contextualised theory of change that was applied by Cordaid and Agence d’Achat de Performance (AAP). In line with the health governance triangle model, the analysis of the present study revolved around three aspects of structural health governance: i) strengthening health governance, which concerns PBF’s effectiveness in terms of the state’s health regulatory capacity and coalition-building; ii) health service provision management, which relates to providers’ expectation management and the improvement of service delivery processes; and iii) demand-side empowerment, which is a requisite for social accountability.
In line with the structural health governance outcomes (see Chapter 4), the following results were found:
PBF as a tool for strengthening health sector governance outcomes: This study found that PBF reinforces the structural governance of the health sector in terms of sector and work organisation, health system management and stakeholder accountability.
PBF empowers the state with organisational capacities while also helping to institutionalise good governance practices. The approach supports the government’s regulatory role, coalition-building and social accountability through enforcing national policy, a division of labour and patient-centred care. Through structural governance building and institutionalisation of good practices, PBF mediates the setting of goals and ideals, as well as building a coalition to work on their implementation. In contrast to other interventions, PBF renders the state more actively visible in system design, coalition-building, regulation and stakeholders’ interactive collaboration.
PBF outcomes on service provision processes management in the Katana HZ: It was found out that the majority of participants in this study viewed PBF favourably. Since PBF was introduced in 2007–2008, the rate of health service utilisation has increased.
This study also found that contracting dealt with the agency problem by motivating health workers and providing performance incentives, thus addressing the laxness observed in the DRC public sector. PBF also provides useful support regarding the
rationalisation of health management. Through promoting contract-based market principles and integrated management, PBF inputs not only attract new health staff, but also improve task-oriented behaviour. This study noted some progress in terms of behavioural change and good practices, such as readiness to improve financial accountability and a commitment to quality, productivity and patient-centred care.
PBF empowers the community for interactive participation: Demand-side empowerment and social accountability are among the principles of PBF and are crucial for health system strengthening. PBF gives power to communities through promoting patient-centred care and recognising communities’ legal and legitimate rights to participate in the process of service provision as both clients and beneficiaries. PBF engages with CBOs, which, in turn, work to raise awareness within the community regarding their social entitlements. Active participation of the community in the process of verifying health facilities’ performance records empowers the population as a key stakeholder in health service management. PBF thus allows the interactive participation of the community, which is necessary to establish a
PBF empowers the community for interactive participation: Demand-side empowerment and social accountability are among the principles of PBF and are crucial for health system strengthening. PBF gives power to communities through promoting patient-centred care and recognising communities’ legal and legitimate rights to participate in the process of service provision as both clients and beneficiaries. PBF engages with CBOs, which, in turn, work to raise awareness within the community regarding their social entitlements. Active participation of the community in the process of verifying health facilities’ performance records empowers the population as a key stakeholder in health service management. PBF thus allows the interactive participation of the community, which is necessary to establish a